Cost of Pacing in Pediatric Patients With Postoperative Heart Block After Congenital Heart Surgery

Key Points Question What is the estimated economic burden of permanent pacemaker (PPM) implantation and management of pacing in pediatric patients after congenital heart surgery (CHS)? Findings In this economic evaluation study using single-institution data of 28 225 patients who underwent CHS, the estimated 20-year mean direct and indirect costs for PPM implantation and management per patient were $180 664 and $15 939, respectively. Complications, though rare, increased these costs to $472 774 and $36 429, respectively. Meaning The findings of this study suggest that PPM implantation due to postoperative heart block in pediatric patients imposes a substantial financial burden on patients and their families; thus, reducing the incidence of PPM implantation should be a focused goal of CHS.


Pacemaker implantation
1. Calculate the difference between the discharge date and index surgery date.
2. If the difference between discharge date and index surgery date <=10 days a. Then LOS was the number of days to the discharge date from the index surgery date.3.If the difference between the discharge date and index surgery date >10 days a. Then LOS was the number of days between PPM implantation and the next procedure (surgery or cath).4. If the calculated LOS was greater than 30 days a. Then LOS value was discarded and not considered in the economic evaluation.
Pacemaker malfunction: generator and lead replacement 1.If the procedure was Outpatient, a. Then LOS = 1 day 2. If the procedure was Inpatient a. Then calculate the difference between the discharge date and the admission date of the malfunction event.3.If the difference between discharge date and admission date <=7 days a. Then LOS was the number of days to the discharge date from the admission date.4. If the difference between the discharge date and admission date >7 days a. Then LOS was the number of days between PPM implantation and the next procedure (surgery or Cath). 5.If the calculated LOS was greater than 30 days a. Then LOS value was discarded and not considered in the economic evaluation

Pacemaker infection
1.If the procedure was Outpatient, a. Then LOS = 3 hours 2. If the procedure was Inpatient a. Then LOS was the difference between the discharge date and the admission date of the infection event.
Pacemaker replacement: battery depletion or generator change 1.If the procedure was Outpatient, a. Then LOS = 3 hours 2. If the procedure was Inpatient a. Then LOS was the difference between the discharge date and the admission date of the pacemaker replacement event.
EP-Cath procedure 1.If the procedure was Outpatient, a. Then LOS = 1 day 2. If the procedure was Inpatient a. Then LOS was the difference between the discharge date and the admission date of the EP-Cath event.

Markov model input parameters
The movement of hypothetical patients through the model was governed by probability input parameters.Adverse event probabilities included each complication and event probabilities for healthcare visits were estimated using the selected patient procedure data.These were patients who had PPM implanted at an age less than 4 years and had at least 6 months of follow-up data.When multiple healthcare utilization for the same event was observed, those that happened more than 7 days apart were considered separate events.Both direct and indirect costs included those related to the treatment of concomitant complications, as well as the cost for the index PPM implantation for each patient from the time of the first implantation until the end of the 20-year time horizon (eTables 1 and 2).The indirect costs for each event were estimated based on the time off of work and US average household income, costs for accommodation, trips to/from the clinic, parking, meals and incidentals.All costs were adjusted to 2018 US dollars. 1

Markov model sensitivity analysis
Point estimates for each input parameter value were used in the base-case analysis.We also performed probabilistic sensitivity analysis (PSA) to assess the impact of uncertainty in all input parameters simultaneously using 1,000,000 (1,000 trials of 1,000 hypothetical patients each) simulated patients.In PSA trials, parameter values were based on random draws from a distribution.Event probabilities were assumed to follow a beta distribution and cost estimates were assumed to follow a gamma distribution.

Cost estimation of clinical courses with and without complication using follow-up data
Direct medical costs for each patient for each year were calculated using estimated event costs (eTable 1) and aggregated to the respective 1-year periods from PPM implantation.Once costs from all patients were binned, the average cost for each year was calculated.Cumulative costs starting from years 1 to 20 were calculated and plotted.Indirect costs or the cost of accompanying a patient for medical care were calculated utilizing LOS for each visit.The cost of lost productivity, accommodation, transportation, and food was included as indirect costs.eTable 2 lists the costs considered for indirect cost calculation.Accommodation costs were considered only for visits with LOS >1 day.The cost of transportation using a personally owned vehicle (POV) per hospital visit was calculated utilizing the national average distance to the nearest pediatric cardiology subspeciality 3 and POV mileage rate (eTable 2, row 4).Like direct costs, costs for all patients were aggregated to the respective year of the event and the average indirect cost for each year and cumulative 20-year cost were calculated.

Statistical Analysis
Linear regression analysis (LR) was performed to determine the dependence of complication cost on LOS and to extrapolate the 20-year costs.R 2 and P values were calculated and used to determine dependence and statistical significance, respectively.Poisson generalized linear model (GLM) was utilized to assess annual trends in CHS, surgical team size and PPM implantation.The model used the following log-link function:log  =  + 1